Form Hfs 3806D PDF Details

If you're a small business owner, then you know that tracking expenses is a vital part of your job. But keeping track of everything can be tricky, especially if you're not sure what all the different forms and abbreviations mean. Today, we're going to take a look at Form HFS 3806D, which is used to track meal and entertainment expenses. We'll explain what each section of the form means, and show you how to fill it out correctly. So whether you're just getting started with running your own business, or you've been in the game for a while but could use a refresher course on Form HFS 3806D, keep reading!

QuestionAnswer
Form NameForm Hfs 3806D
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesillinois department of healthcare and family services, HIV, determinations, HFS

Form Preview Example

State of Illinois

Department of Healthcare and Family Services

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

NOTICE:

•Federal law says that Healthcare and Family Services (HFS) cannot share your health information without your permission except in certain situations. If you sign this form, you are giving HFS permission to share your health information that HFS has with the person you indicate below.

•This authorization is voluntary.

•Right to revoke : If you decide you do not want HFS to share your health information any longer, sign the revocation at the end of this form and give this form to HFS. If HFS has shared your health information for a research study, HFS may continue to use or share your health information for that purpose only.

•Payment, enrollment or eligibility for benefits for your health care will not be affected if you do not sign this authorization, unless the disclosure is for eligibility or enrollment determinations, or for risk determinations.

•HFS cannot promise that the person you permit HFS to share your health information with will not share your health information with someone else you may not want to have your health information.

•You can keep a copy of this authorization, and can contact the HFS privacy officer to get a copy if you do not have one.

My name (print)

 

 

Date of Birth

 

 

 

 

 

Social Security Number

 

Recipient I.D. Number

 

I give permission to: Healthcare and Family Services to share my health information with:

so that this person or entity may assist me with my health care issues.

HFS may share my health information for one year after the date on this authorization form or until I revoke the authorization.

I want HFS to share this health information: (check all boxes that apply)

All of my health information

Information regarding prescription drug coverage

My health information regarding Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV)

My health information regarding treatment for alcohol and/or substance abuse

My health information regarding behavioral health services or psychiatric care

Other

This form must be signed by EITHER the recipient OR by the personal representative. The recipient's parent may sign for the recipient if the recipient is a minor.

Signature of Recipient

 

Date

If this form is signed by the personal representative, please include a copy of the document naming the personal representative, for example, a power of attorney, Personal Representative Designation form, or order appointing a guardian or executor.

Signature of personal representative

 

Date

Relationship of personal representative

HFS 3806D (R-6-09)

Page 1 of 2

REVOCATION OF AUTHORIZATION

I no longer want Healthcare and Family Services to share my health information with the person or entity indicated above.

My name (print)

Social Security Number

Signature

 

Date

Send this Authorization Form

If you have any questions, contact the

or Revocation of Authorization to:

Privacy Office at the address to the left,

 

or the phone number below. The call is free.

Privacy Officer

 

Healthcare and Family Services

Toll-free telephone: 1-800-226-0768

P.O. Box 19159

(Health Benefits Hotline)

Springfield, Illinois 62794-9159

Toll-free for persons

 

using a TTY: 1-877-204-1012

Fax: 1-217-524-2397

 

 

e-mail address: privacy.officer@illinois.gov

HFS 3806D (R-6-09)

Page 2 of 2

How to Edit Form Hfs 3806D Online for Free

Any time you want to fill out Designation, you won't have to download and install any sort of programs - just make use of our PDF tool. Our tool is constantly evolving to deliver the best user experience attainable, and that's due to our resolve for continual development and listening closely to comments from users. With a few simple steps, you can begin your PDF editing:

Step 1: First, access the pdf editor by clicking the "Get Form Button" at the top of this site.

Step 2: This tool lets you modify nearly all PDF files in many different ways. Improve it with your own text, adjust what's originally in the PDF, and include a signature - all close at hand!

It is actually straightforward to finish the pdf using this practical guide! This is what you want to do:

1. It's vital to complete the Designation properly, so take care when working with the segments including all these blank fields:

The right way to prepare illinois department of healthcare and family services portion 1

2. The subsequent stage is usually to fill in these particular blanks: If this form is signed by the, Signature of personal, Date, Relationship of personal, HFS D R, and Page of.

How you can complete illinois department of healthcare and family services part 2

3. The following section is focused on I no longer want Healthcare and, My name print, Social Security Number, Signature, Date, Send this Authorization Form or, and If you have any questions contact - fill in every one of these blank fields.

Date, Signature, and Social Security Number in illinois department of healthcare and family services

4. The next part needs your involvement in the subsequent parts: Send this Authorization Form or, and If you have any questions contact. Ensure that you provide all of the required details to move forward.

Completing segment 4 in illinois department of healthcare and family services

You can easily make an error when completing your If you have any questions contact, therefore ensure that you take another look prior to deciding to send it in.

Step 3: Before getting to the next step, ensure that all blank fields are filled out right. Once you confirm that it is fine, click on “Done." Get hold of your Designation when you join for a free trial. Conveniently access the pdf file within your personal account page, together with any modifications and adjustments automatically saved! FormsPal guarantees your information privacy with a secure method that in no way saves or distributes any type of personal information provided. Feel safe knowing your files are kept safe every time you work with our services!

Form Hfs 3806D isn’t the one you’re looking for?

Related Documents